Animal And Insect Bites

ANIMAL & INSECT ANIMAL & INSECT BITESBITES

James Taclin C. Banez, MD, FPCS, James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, DPSA FPSGS, DPBS, DPSA

RABIESRABIES In any mammalian animalIn any mammalian animal Rhabdovirus:Rhabdovirus:

1.1. RabiesRabies – meningoencephalitis – meningoencephalitis

- worldwideworldwide

2.2. EbolaEbola – hemorrhagic fever– hemorrhagic fever

3.3. MarburgMarburg – hemorrhagic fever – hemorrhagic fever AfricaAfrica

RABIESRABIES Developed countries ---> raccoons, Developed countries ---> raccoons,

skunks, bats, skunks, bats, etcetc

Developing and under developedDeveloping and under developed– Dogs (90%-Phil.)Dogs (90%-Phil.)

Cats, cattle, horse, sheep, bats and Cats, cattle, horse, sheep, bats and exotic animals (5-10%)exotic animals (5-10%)

Small rodents, birds and reptiles does Small rodents, birds and reptiles does not serve as reservoir of infectionnot serve as reservoir of infection

Epidemiology (Rabies)Epidemiology (Rabies)

Incidence rate: Incidence rate: – 5–7/million5–7/million– Average cases: 450 annually (Phil.)Average cases: 450 annually (Phil.)– Philippine is 3Philippine is 3rdrd worldwide worldwide– San Lazaro Hospital:San Lazaro Hospital:

Pet dogs – 88% of casesPet dogs – 88% of casesStray dogs – 10% of casesStray dogs – 10% of casesCats – 2% of casesCats – 2% of cases

PreventionPrevention Avoidance of said animalsAvoidance of said animals Vaccination of pets (dogs, cats)Vaccination of pets (dogs, cats) Exotic animals:Exotic animals:

– Quarantine for 90 days then vaccinate Quarantine for 90 days then vaccinate after another 30 daysafter another 30 days

– Pet bitten by rabid animals:Pet bitten by rabid animals:No previous vaccine ---> isolate for 6 No previous vaccine ---> isolate for 6

months, vaccinate 1 month---->releasemonths, vaccinate 1 month---->releasew/ vaccine ----> give vaccine again and w/ vaccine ----> give vaccine again and

isolated for 90 daysisolated for 90 days

TransmissionTransmission

1.1. Bites of rabid animalsBites of rabid animals

2.2. Licking of the mucosa or open Licking of the mucosa or open woundwound

Period of communicabilityPeriod of communicability::– Dogs & cats = Dogs & cats = 3-5 days3-5 days before the before the

onset of the symptoms until the onset of the symptoms until the entire course of the illness.entire course of the illness.

TransmissionTransmission Incubation periods (Human):Incubation periods (Human):

– 1 days to 5 yrs.1 days to 5 yrs. (average (average 8wks8wks))– Variations:Variations:

1.1. Severity of the biteSeverity of the bite

2.2. Site of bite in relation to nerve supply Site of bite in relation to nerve supply and distance from CNSand distance from CNS

3.3. Size of innoculum, protection offered Size of innoculum, protection offered by clothing and other factorsby clothing and other factors

4.4. Age and immune status of the hostAge and immune status of the host

TransmissionTransmission Virus stays inVirus stays in::

1.1. CNSCNS

2.2. LiverLiver

3.3. Salivary glandSalivary gland Travels thru the Travels thru the nervenerve Incubation periods:Incubation periods:

– 1 days to 5 yrs. (average 8wks)1 days to 5 yrs. (average 8wks)

DiagnosisDiagnosis Circumstances of bite:Circumstances of bite:

– Provokes/unprovoked (domestic)Provokes/unprovoked (domestic)– Vaccination of dogs ----> 90% effectiveVaccination of dogs ----> 90% effective– Wild animalWild animal ----> considered rabid ----> considered rabid

Extent & location of bite:Extent & location of bite:1.1. Severe: Severe:

multiple or deep puncture woundmultiple or deep puncture wound Head, face, neck hands or fingersHead, face, neck hands or fingers

2.2. Mild:Mild: Superficial laceration, scratchesSuperficial laceration, scratches Bites on other sites mentionedBites on other sites mentioned

DiagnosisDiagnosis Laboratory diagnosis:Laboratory diagnosis:

1.1. Pre-mortem (human):Pre-mortem (human): Fluorescent microscopy of skin biopsies from Fluorescent microscopy of skin biopsies from

nape of the neck.nape of the neck. Isolation of virus from saliva and CSFIsolation of virus from saliva and CSF Detection of antibody in serum and CSF in Detection of antibody in serum and CSF in

unvaccinated personunvaccinated person

2.2. Postmortem (human):Postmortem (human): Fluorescent microscopy of brain and salivary Fluorescent microscopy of brain and salivary

glandgland

3.3. Animal brainAnimal brain:: Histology = negri bodiesHistology = negri bodies

– Demonstration of virus in brain tissueDemonstration of virus in brain tissue

Natural History of Clinical Rabies Natural History of Clinical Rabies in Manin Man

Infected pts. usually go through 4 stages:Infected pts. usually go through 4 stages:

Exposure:Exposure:I.I. Incubation Period Incubation Period 20-90 days:20-90 days:

– >95% present s/sx w/in 6 months of exposure>95% present s/sx w/in 6 months of exposure– >98% w/in 1 yr.>98% w/in 1 yr.

II.II. First Symptoms First Symptoms (Prodrome)(Prodrome) 2-10 days 2-10 days– Virus reaches the spinal cordVirus reaches the spinal cord– Nonspecific s/sx:Nonspecific s/sx:

− Fever, Anorexia, N/V, Headache, Malaise, lethargyFever, Anorexia, N/V, Headache, Malaise, lethargy

− 11stst rabies specific symptom: rabies specific symptom:− Pain , itching or paresthesias at site of bitePain , itching or paresthesias at site of bite


III.III. First Neurological Signs/Acute First Neurological Signs/Acute Neurological Phase: Neurological Phase: 2-7 days2-7 days

– Virus reaches the brain, multiplies and Virus reaches the brain, multiplies and disseminates rapidly to the rest of the body disseminates rapidly to the rest of the body organs notably the salivary glandsorgans notably the salivary glands

– Pt may die at this stagePt may die at this stage



– May present in 2 ways:May present in 2 ways:a.a. Encephalitic or Furious rabiesEncephalitic or Furious rabies (80%): (80%):

Hyperactive episodes:Hyperactive episodes:– Combative, presents bizarre behavior, may Combative, presents bizarre behavior, may

be very agitated or apprehensivebe very agitated or apprehensive– Alternating w/ lucid moments where pt Alternating w/ lucid moments where pt

appears wellappears well Hydrophobia Hydrophobia – elicited by giving pt glass of – elicited by giving pt glass of

water; positive rxn. – agitation, caused by water; positive rxn. – agitation, caused by painful contraction of laryngeal muscles upon painful contraction of laryngeal muscles upon drinkingdrinking

Aerophobia Aerophobia – elicited by fanning the pt– elicited by fanning the pt



– May present in 2 ways:May present in 2 ways:b.b. Paralytic or “dumb” rabiesParalytic or “dumb” rabies (20%) (20%)

Starts as paralysis of the bitten area w/c Starts as paralysis of the bitten area w/c spreads to involve all limbs and eventually spreads to involve all limbs and eventually ends in respiratory paralysisends in respiratory paralysis

Most often missed due to absent hydrophobia Most often missed due to absent hydrophobia and aerophobiaand aerophobia

High index of suspicion who came in w/ High index of suspicion who came in w/ paralysis or encephalitis of undetermined paralysis or encephalitis of undetermined etiology.etiology.

Hx of prior exposure (bite or non-bite)Hx of prior exposure (bite or non-bite)


IV.IV. Onset of Coma Onset of Coma 0-14d0-14d− Pituitary dysfunctionPituitary dysfunction− Hypoventilation, apneaHypoventilation, apnea− HypotensionHypotension− Cardiac arrhythmia, cardiac arrestCardiac arrhythmia, cardiac arrest− ComaComa

V.V. Death:Death:− Secondary infection, nutritional deficiency and Secondary infection, nutritional deficiency and

respiratory problemrespiratory problem

ManagementManagement

Biting animals:Biting animals:– Domestic = observe for 10 daysDomestic = observe for 10 days– Wild = vaccine shd. be givenWild = vaccine shd. be given

Patients management:Patients management:1.1. Immediate local care:Immediate local care:

Thorough irrigation w/ copious water/soapThorough irrigation w/ copious water/soap Debridement / antibiotic / tetanus toxoidDebridement / antibiotic / tetanus toxoid Immediate suturing of wound (not advisable)Immediate suturing of wound (not advisable)


Patients management:Patients management:1.1. Immediate local careImmediate local care::

a.a. Head & neck bites:Head & neck bites: Healing by secondary intention produces Healing by secondary intention produces

an unacceptable scar.an unacceptable scar. Primary closure has best outcome w/ less Primary closure has best outcome w/ less

risk of infectionrisk of infection Severe human bite and avulsion injuries of Severe human bite and avulsion injuries of

the face requires flaps to close the woundthe face requires flaps to close the wound

ManagementManagement Patients management:Patients management:

1.1. Immediate local care:Immediate local care:

b.b. Hand Injuries:Hand Injuries: 1/3 of dog bites in the hand becomes 1/3 of dog bites in the hand becomes

infected even w/ adequate therapyinfected even w/ adequate therapy Healing by secondary intention is Healing by secondary intention is

recommended for most hand laceration.recommended for most hand laceration. All tendons and nerve injuries should be All tendons and nerve injuries should be

managed by delayed repairmanaged by delayed repair After thorough exploration, irrigation and After thorough exploration, irrigation and

debridement, the hand shd. be debridement, the hand shd. be immobilized, wrapped in a bulky dressingimmobilized, wrapped in a bulky dressing

ManagementManagement Patients management:Patients management:

1.1. Immediate local care:Immediate local care:

c.c. Other parts of the body:Other parts of the body:


Patients management:Patients management:2.2. Prophylaxis:Prophylaxis:– Post-exposure prophylaxis:Post-exposure prophylaxis:

Incubation period 10 days to 1 year (20-90d)Incubation period 10 days to 1 year (20-90d) Incubation of <30 days (head & neck, upper Incubation of <30 days (head & neck, upper

extremities)extremities)

ManagementManagement Prophylaxis:Prophylaxis:

Immunization:Immunization:1.1. Passive:Passive:

Human Rabies Immune Globulin (HRIG)Human Rabies Immune Globulin (HRIG)– 20 I.U./KgBW20 I.U./KgBW

Equine Rabies Immune GlobulinEquine Rabies Immune Globulin– 40 I.U./KgBW40 I.U./KgBW

– A portion is infiltrated into the woundA portion is infiltrated into the wound– Given with in 8 daysGiven with in 8 days

ManagementManagement Prophylaxis:Prophylaxis:

Immunization:Immunization:

2.2. Active:Active: Human Diploid Cell Vaccine (HDCV)Human Diploid Cell Vaccine (HDCV)

– 5 dose IM (1ml) ----> 0, 35 dose IM (1ml) ----> 0, 3rdrd, 7, 7thth,14,14thth and 28 and 28thth days days WHO - 90 WHO - 90thth day day

– Booster:Booster: HDCV – 2 dose (0 and 3HDCV – 2 dose (0 and 3rdrd day) day) Antibodies levels checked every 6 monthsAntibodies levels checked every 6 months


TYPE OF EXPOSURETYPE OF EXPOSURETREATMENTTREATMENT

HEALTHYHEALTHY SICK/RABIDSICK/RABID

Category I:Category I:Touching or feeding, licking of healthy Touching or feeding, licking of healthy skin w/ no open wound, no documented skin w/ no open wound, no documented contact of saliva w/ mucous membrane, contact of saliva w/ mucous membrane, reliable historyreliable history

No No treatmenttreatment

No No

treatmenttreatment

Category II:Category II:Nibbling of uncovered skin, superficial Nibbling of uncovered skin, superficial scratch that doesn’t break skin, licking scratch that doesn’t break skin, licking over broken skin or healing wounds. over broken skin or healing wounds. Category I w/ unrealiable historyCategory I w/ unrealiable history

Vaccine + Vaccine + observeobserve

Vaccine Vaccine

(full course)(full course)

Category III:Category III:

Single or multiple transdermal bite or Single or multiple transdermal bite or scratch which penetrates skin at any scratch which penetrates skin at any location; licking of mucous membranelocation; licking of mucous membrane

Vaccine + Vaccine + RIG + RIG +

observeobserve

Vaccine + RIG Vaccine + RIG + (Full + (Full course)course)

WHO GUIDE FOR POST-EXPOSURE TREATMENT:Assess Nature of Contact or Injury and the Biting Animals

ManagementManagement Side effects of Vaccine (HBCV):Side effects of Vaccine (HBCV):

– Sickness, pain and swelling of injection Sickness, pain and swelling of injection sitesite

– Fever, N/V, diarrhea, lymphadenopathyFever, N/V, diarrhea, lymphadenopathy– Headache and dizzinessHeadache and dizziness

Contraindications:Contraindications:1.1. Immuno-suppressive agents (measure Immuno-suppressive agents (measure

antibody titer)antibody titer)

2.2. Allergies (antihistamine and epinephrine)Allergies (antihistamine and epinephrine)

3.3. Pregnancy (not accepted nor Pregnancy (not accepted nor documented)documented)

ManagementManagement Treatment for symptomatic patients:Treatment for symptomatic patients: Supportive:Supportive:

– SedationSedation– Respiratory supportRespiratory support– Management heart arrhythmia and Management heart arrhythmia and

seizuresseizures– Nursing careNursing care– INTERFERONINTERFERON (not effective) (not effective)

SNAKE BITE

SNAKE BITESSNAKE BITESCharacteristicCharacteristic Poisonous Poisonous Nonpoisonous Nonpoisonous

a. Shape of a. Shape of head head

triangular round

b. Pitb. Pit (+) (-)

c. Pupilsc. Pupils elliptical Round

d. Bite marksd. Bite marks Fang marks 2 rows of teeth

e. Caudal platese. Caudal plates Single row Double row

f. Color bodyf. Color bodyRed ring next to

yellow (coral snakes)

Alternating color

Venom SnakesVenom Snakes Toxicology:Toxicology:

1.1. Peptides:Peptides: Damages the endothelium:Damages the endothelium:

– Increase vascular permeabilityIncrease vascular permeability Edema and hypovolemic Edema and hypovolemic

2.2. Enzymes:Enzymes:a.a. Proteases & L-amino acid oxidaseProteases & L-amino acid oxidase::

– Cause tissue necrosisCause tissue necrosis

b.b. Hyaluronidase:Hyaluronidase:– Facilitate spread of venom through tissueFacilitate spread of venom through tissue

c.c. Phospholipase A2:Phospholipase A2:– Damages erythrocytes and muscle cells.Damages erythrocytes and muscle cells.

Venom SnakesVenom Snakes4.4. Neurotoxin:Neurotoxin:

Blocks neuromuscular junctionBlocks neuromuscular junction

5.5. Others:Others: Endonuclease, alkaline and acid Endonuclease, alkaline and acid

phosphatase, cholinesterasephosphatase, cholinesterase

Other deleterious effect:Other deleterious effect:– Affects cardiovascular, pulmonary, Affects cardiovascular, pulmonary,

renal and neurologic systemsrenal and neurologic systems– Affects coagulation, fibrinolysis, Affects coagulation, fibrinolysis,

platelet function and vascular integrity platelet function and vascular integrity causing hemorrhagic or thrombotic causing hemorrhagic or thrombotic sequelaesequelae

Clinical ManifestationsClinical Manifestations

Local:Local:– 20% of pit vipers do not cause 20% of pit vipers do not cause

envenomationenvenomation– Venom causes burning pain w/in Venom causes burning pain w/in

minutes, followed by edema and minutes, followed by edema and erythema ----> edema progresses over erythema ----> edema progresses over the next few hrs w/ development of the next few hrs w/ development of ecchymoses and hemorrhagic bullaeecchymoses and hemorrhagic bullae

Clinical ManifestationsClinical ManifestationsSystemic:Systemic:

– Pt usually complain of weakness, N/V, Pt usually complain of weakness, N/V, perioral paresthesias, metallic taste perioral paresthesias, metallic taste and fasiculations.and fasiculations.

– Continuing capillary leak leads to Continuing capillary leak leads to hypotensionhypotension ---> ---> shock, pulmonary shock, pulmonary edemaedema

– CoagulopathyCoagulopathy can develop w/in an can develop w/in an hour and manifest:hour and manifest:

Bleeding (gingiva, bite site, venipuncture Bleeding (gingiva, bite site, venipuncture site and recent woundssite and recent wounds

Leads to DIC (disseminated intravascular Leads to DIC (disseminated intravascular coagulopathy)coagulopathy)

Clinical ManifestationsClinical ManifestationsSystemic:Systemic:

– Acute renal failureAcute renal failure due to:due to:1.1. Direct nephrotoxinDirect nephrotoxin

2.2. Circulatory collapseCirculatory collapse

3.3. Consumption coagulopathyConsumption coagulopathy

– Neurotoxic venom (black Neurotoxic venom (black mamba/coral snake/sea snake):mamba/coral snake/sea snake):

Local injury is minimal or absentLocal injury is minimal or absent Cranial nerve dysfunction and loss of deep Cranial nerve dysfunction and loss of deep

tendon reflexes tendon reflexes Progress to respiratory depression and Progress to respiratory depression and

paralysis after several hours.paralysis after several hours.

Laboratory ExaminationLaboratory Examination

– CBCCBC– DIC panelDIC panel– Serum electrolyteSerum electrolyte– BUN, CreatinineBUN, Creatinine– UrinalysisUrinalysis– ECGECG

ManagementManagementField Therapy:Field Therapy:

– Calm the pt.Calm the pt. / cleansed / immobilized / cleansed / immobilized below the level of the heart.below the level of the heart.

– TourniquetTourniquet, to occlude the vein; , to occlude the vein; removed when: removed when:

1.1. as soon as IVF is startedas soon as IVF is started

2.2. Antivenom is ready for administrationAntivenom is ready for administration

3.3. Patient is not in shockPatient is not in shock

ManagementManagementField Therapy:Field Therapy:

– Incision & Suction:Incision & Suction: Effective if done w/in 5 mins and continued Effective if done w/in 5 mins and continued

for at least 30 minutes.for at least 30 minutes. If done > 5mins ----> loss 50% 0f it’s valueIf done > 5mins ----> loss 50% 0f it’s value If delayed > 30mins ----> loss 100% valueIf delayed > 30mins ----> loss 100% value

– Excision of the bite wound:Excision of the bite wound: In severe bitesIn severe bites Pt allergic to horse serumPt allergic to horse serum Those pt. seen w/in 1 hr. following the bitThose pt. seen w/in 1 hr. following the bit

– CryotherapyCryotherapy – not recommended – not recommended

ManagementManagementHospital Management:Hospital Management:

– History:History: Hx. Of incidentHx. Of incident Type of snakeType of snake Field management and prior antivenin tx.Field management and prior antivenin tx.

– PE:PE: Vital signsVital signs Size and wound appearance (degree of Size and wound appearance (degree of

envenomation / neurological examination for envenomation / neurological examination for coral snake)coral snake)

ManagementManagementHospital Management:Hospital Management:Wound care:Wound care:

– Cleansed thoroughly and extremity splintedCleansed thoroughly and extremity splinted– Debridement if necessaryDebridement if necessary– Tetanus toxoid and tetanus immune globulinTetanus toxoid and tetanus immune globulin– Broad spectrum antibiotic (3-5days)Broad spectrum antibiotic (3-5days)

Fasciotomy:Fasciotomy:– Done only if compartment pressure are over Done only if compartment pressure are over

30mmhg.30mmhg.– Routine fasciotomies to prevent compartment Routine fasciotomies to prevent compartment

syndrome have not proved to be beneficial.syndrome have not proved to be beneficial.

ManagementManagementHospital Management:Hospital Management:Degree of Envenomation:Degree of Envenomation:

Grade 0: Grade 0: No envenomationNo envenomation– Minimal pain in wound, <1 inch of edema & Minimal pain in wound, <1 inch of edema &

erythema, no systemic symptomserythema, no systemic symptoms

Grade I:Grade I: MinimalMinimal– Moderate to severe painModerate to severe pain– 1-5inches edema & erythema at 12hrs.1-5inches edema & erythema at 12hrs.– No systemic symptomsNo systemic symptoms


Grade II: Grade II: ModerateModerate– Severe painSevere pain– 6-12inches of edema & erythema at 12hrs.6-12inches of edema & erythema at 12hrs.– N/V, shock or neurotoxic symptomsN/V, shock or neurotoxic symptoms

Grade III:Grade III: SevereSevere– Severe pain, >12 inches edema/erythema at 12hrsSevere pain, >12 inches edema/erythema at 12hrs– Grade II plus generalized petechia and ecchymosisGrade II plus generalized petechia and ecchymosis


Grade IV: Grade IV: Very SevereVery Severe– Renal failure/blood tinged secretionsRenal failure/blood tinged secretions– Coma and deathComa and death– Local edema extend beyond involved extremityLocal edema extend beyond involved extremity

Antivenin TherapyAntivenin Therapy Most important txMost important tx

Horse serum; Horse serum; skin testingskin testing (0.02ml of (0.02ml of 1:10 dilution of antivenum w/ 0.9% 1:10 dilution of antivenum w/ 0.9% NaCl intradermally).NaCl intradermally).– (+) allergy ----> premedication w/ (+) allergy ----> premedication w/

diphenhydramine HCLdiphenhydramine HCL 25-50ug IV and 25-50ug IV and an epinephrine drip (2-20ug/min) during an epinephrine drip (2-20ug/min) during antivenin administration.antivenin administration.

Antivenin TherapyAntivenin Therapy Antivenin dose depends on the Antivenin dose depends on the

severity of envenomation and severity of envenomation and administered over 2-4hrs.administered over 2-4hrs.

Grade IGrade I == No antiveninNo antiveninGrade IIGrade II == 3-4 amp. in 500ml NSS3-4 amp. in 500ml NSSGrade IIIGrade III == 5-15amp. in 500ml NSS5-15amp. in 500ml NSS

Pt re-evaluated every Pt re-evaluated every 2hrs2hrs and if and if necessary a repeat dose of ativenin necessary a repeat dose of ativenin shld be evaluated and given. shld be evaluated and given.

Antivenin TherapyAntivenin Therapy Children: antivenin be increased Children: antivenin be increased

by 50% bec. of higher rate of by 50% bec. of higher rate of venom to body mass.venom to body mass.

Pregnancy is not contraindicated Pregnancy is not contraindicated

Antivenin for coral snake bite should Antivenin for coral snake bite should be initiated even if envenomation is be initiated even if envenomation is only suspected for there are only suspected for there are frequently no local manifestationfrequently no local manifestation

Antivenin TherapyAntivenin Therapy

King cobra & Black mamba snakeKing cobra & Black mamba snake bites (Quick acting venom)bites (Quick acting venom)– The initial dose of antivenin is part of it’s The initial dose of antivenin is part of it’s

first aid tx. first aid tx.

Other form of ManagementOther form of Management

Need for respirator ---> for Need for respirator ---> for respiratory failurerespiratory failure

Dialysis ----> for renal failureDialysis ----> for renal failure CNS DecompressionCNS Decompression Transfusion of blood and its Transfusion of blood and its

derivativesderivatives NutritionNutrition

ARTHROPOD ARTHROPOD BITEBITE

HymenopteraHymenoptera BEES BEES (Honeybee/bumble bee/ black (Honeybee/bumble bee/ black

hornet),hornet), – Venom: drop by drop similar to rattle Venom: drop by drop similar to rattle

snakesnake– Bees has a barb-shaped stinger Bees has a barb-shaped stinger – Venom:Venom:

1.1. HHistamine/serotoninistamine/serotonin (local rxn & (local rxn & pain)pain)– Causes tissue necrosisCauses tissue necrosis

2.2. Phospholipase/hyaluronidase Phospholipase/hyaluronidase – Destroy collagenDestroy collagen– Allergen – can elicit IgE mediated Allergen – can elicit IgE mediated

responseresponse

ManifestationManifestation

Local rxn:Local rxn:– Sting produced localize pain, Sting produced localize pain,

wheal --> pustulewheal --> pustule– 20% produced large local rxn as 20% produced large local rxn as

erythematous, edematous, painful erythematous, edematous, painful and pruritic areas larger than 10cm. and pruritic areas larger than 10cm. For 2-5 daysFor 2-5 daysRepresents combination of IgE mediated, Represents combination of IgE mediated,

cell mediated cell mediated

ManifestationManifestationSystemic rxn:Systemic rxn:

– Multiple stings can produced toxic Multiple stings can produced toxic rxns.rxns.

1.1. Vomiting, diarrhea, generalized edemaVomiting, diarrhea, generalized edema

2.2. Cardiovascular collapse Cardiovascular collapse

3.3. HemolysisHemolysis

– 3% causes death due to 3% causes death due to anaphylaxis w/in 1 hr.anaphylaxis w/in 1 hr.

Starts as urticaria ----> Starts as urticaria ----> angioedemaangioedema, , respiratory arrestrespiratory arrest 2 2ndnd to airway to airway edema and cardiovascular collapseedema and cardiovascular collapse

TreatmentTreatmentLocal therapy:Local therapy:

– Removal of sting (gentle scraping)Removal of sting (gentle scraping)– Clean the siteClean the site– Pain: Pain: - apply ice- apply ice

- vinegar- vinegar- topical or injected lidocaine- topical or injected lidocaine

– Pruritus:Pruritus: - antihistamine- antihistamine– Larger area: – elevate the siteLarger area: – elevate the site

- analgesia- analgesia - prednisone - prednisone

(1mg/k/day)(1mg/k/day)

TreatmentTreatmentSystemic therapy:Systemic therapy: Mild anaphylaxisMild anaphylaxis::

– 0.3 ml of 1:1000 epinephrine subQ 0.3 ml of 1:1000 epinephrine subQ (children – 0.01ml/kg)(children – 0.01ml/kg)

– Oral or IV antihistamineOral or IV antihistamine

Severe anaphylaxis:Severe anaphylaxis:– IVFIVF - endotracheal intubation - endotracheal intubation– Vasopressor - steroid Vasopressor - steroid – Bronchodilator - ICU monitoringBronchodilator - ICU monitoring

SpidersSpidersI.I. Lactrodectus spidersLactrodectus spiders (Black (Black

Widow)Widow)– WorldwideWorldwide– female: black color w/ a distinctive red female: black color w/ a distinctive red

ventral marking w/ hourglass shapeventral marking w/ hourglass shape– Nocturnal spider; bites defensivelyNocturnal spider; bites defensively– Has Has neurotoxic venomneurotoxic venom

Act at presynaptic terminalAct at presynaptic terminal Enhance neurotransmitter releaseEnhance neurotransmitter release

– AcetylcholineAcetylcholine = neuromuscular junction (muscle = neuromuscular junction (muscle spasm)spasm)

– NorepinephrineNorepinephrine = produces adrenergic = produces adrenergic stimulationstimulation

SpidersSpidersI.I. Lactrodectus spidersLactrodectus spiders ( (Black Black

Widow)Widow)Manifestation:Manifestation:

− Erythema & pain at bite siteErythema & pain at bite site− Neuromuscular symptoms (30mins)Neuromuscular symptoms (30mins)

Severe pain & spasm of large muscle grpSevere pain & spasm of large muscle grp1.1. Abdominal cramps (like acute abd)Abdominal cramps (like acute abd)2.2. Dyspnea (chest tightness)Dyspnea (chest tightness)

Adrenergic stimulation:Adrenergic stimulation:1.1. HPN / diaphoresis / tachycardiaHPN / diaphoresis / tachycardia2.2. Fasciculation / Nausea/vomitingFasciculation / Nausea/vomiting3.3. Headache / paresthesia / fatigue / salivationHeadache / paresthesia / fatigue / salivation

Acute symptoms peak several hours & resolve in Acute symptoms peak several hours & resolve in 1-2 days1-2 days

Death unusualDeath unusual

SpidersSpidersI.I. Lactrodectus spidersLactrodectus spiders (Black Widow)(Black Widow)

Treatment:Treatment:a.a. Mild envenomationMild envenomation

Local wound care:Local wound care:– Clean the siteClean the site– Apply ice – to alleviate painApply ice – to alleviate pain– tetanus prophylaxistetanus prophylaxis

b.b. Severe envenomationSevere envenomation IV IV calcium gluconate calcium gluconate (transient effect)(transient effect) Narcotic & benzodiazepine - relieve muscle Narcotic & benzodiazepine - relieve muscle

painpain Antivenin (horse serum) – reserve for severe Antivenin (horse serum) – reserve for severe

envenomation due to anaphylaxis & serum envenomation due to anaphylaxis & serum sickness (side effect)sickness (side effect)

SpidersSpidersI.I. Lactrodectus spidersLactrodectus spiders (Black Widow)(Black Widow)

Treatment:Treatment:b.b. Severe envenomationSevere envenomation

– Antivenum is recommended:Antivenum is recommended:1.1. Pregnant womenPregnant women2.2. Children under 16 yrsChildren under 16 yrs3.3. Patients w/ severe reaction:Patients w/ severe reaction:

– Uncontrolled HPNUncontrolled HPN– Respiratory distressRespiratory distress– SeizuresSeizures

– Skin testing = if (+) shd. Receive pretx w/ Skin testing = if (+) shd. Receive pretx w/ diphenhydramine.diphenhydramine.

– Recommended antivenin dose = 1 vial, Recommended antivenin dose = 1 vial, repeated as necessaryrepeated as necessary

SpidersSpidersII.II. Brown RecluseBrown Recluse (loxosceles):(loxosceles):

– Necrotic arachnidism / loxoscelismNecrotic arachnidism / loxoscelism– North & South America, Africa & North & South America, Africa &

EuropeEurope– Char. = dark brown Char. = dark brown violin shapeviolin shape

marking over the cephalothoraxmarking over the cephalothorax Has 3 pairs of eyeHas 3 pairs of eye Both male & female bites when threatenedBoth male & female bites when threatened


Toxicology:Toxicology:– SphingomyelinaseSphingomyelinase (phospholipase) (phospholipase)

1.1. Dermonecrotic factorDermonecrotic factor2.2. Destroy cell membrane or RBC ---> hemolysisDestroy cell membrane or RBC ---> hemolysis3.3. Destroy endothelial cells ---> coagulationDestroy endothelial cells ---> coagulation4.4. Interact w/ platelets ----> platelet Interact w/ platelets ----> platelet

aggregationaggregation

Necrosis – most severe in fatty areas Necrosis – most severe in fatty areas (abdomen & thigh) (abdomen & thigh)


Manifestation:Manifestation:

Local:Local: Mild irritation to severe necrosis w/ ulcerationMild irritation to severe necrosis w/ ulceration

Ischemia (pain, itching, swelling & erythema) ---> Ischemia (pain, itching, swelling & erythema) ---> blister ----> central area turns purple and blister ----> central area turns purple and peripheral becomes pale due to vasoconstriction peripheral becomes pale due to vasoconstriction ----> necrosis ---> replaced by eschar that ----> necrosis ---> replaced by eschar that separates producing ----> large ulcer that heals separates producing ----> large ulcer that heals w/in 2 months.w/in 2 months.


Manifestation:Manifestation:

Systemic:Systemic:– N/V, headache, fever, malaise, arthralgiaN/V, headache, fever, malaise, arthralgia– Maculopapular rashMaculopapular rash

Thrombocytopenia / Disseminated intravascular Thrombocytopenia / Disseminated intravascular coagulationcoagulation

Hemolytic anemiaHemolytic anemia Coma and rarely deathComa and rarely death


Treatment:Treatment:– Bite site elevatedBite site elevated– Cold compress: Cold canCold compress: Cold can

1.1. Inhibits venomInhibits venom2.2. Decrease inflammation & ulcer formationDecrease inflammation & ulcer formation

– Dapson Dapson = reduces local inflammation by = reduces local inflammation by inhibiting neutrophil function. (100mg/d)inhibiting neutrophil function. (100mg/d)

– Debridement is recommended be done 1-2 wks Debridement is recommended be done 1-2 wks after the margin are definedafter the margin are defined

– Split thickness skin grafting done while dapsone Split thickness skin grafting done while dapsone is being continuedis being continued

– No antiveninNo antivenin

ScorpionScorpion Worldwide / Buthidae familyWorldwide / Buthidae family Has neurotoxin that prevent sodium Has neurotoxin that prevent sodium

channel closurechannel closure

Manifestation:Manifestation:– Local paresthesia & burning symptomsLocal paresthesia & burning symptoms– Cranial nerves & neuromuscular Cranial nerves & neuromuscular

dysfunction ----> respiratory distressdysfunction ----> respiratory distress

ScorpionScorpionTreatment:Treatment:Local:Local:

– Ice pack therapy / analgesic -> for painIce pack therapy / analgesic -> for pain– Tetanus prophylaxisTetanus prophylaxis

Systemic:Systemic:– Monitor closely cardiovascular & respiratory Monitor closely cardiovascular & respiratory

status in ICUstatus in ICU– AntiveninAntivenin can reverses cranial nerve & can reverses cranial nerve &

neuromuscular symptoms but can cause neuromuscular symptoms but can cause anaphylaxis & delayed serum sicknessanaphylaxis & delayed serum sickness

– Dose = 1 vial; if sensitive (diphenhydramine)Dose = 1 vial; if sensitive (diphenhydramine)

Marine Trauma & Marine Trauma & EnvenomationEnvenomation

Considerations:Considerations:1.1. HypothermiaHypothermia

2.2. DrowningDrowning

3.3. Decompression syndrome (air Decompression syndrome (air embolism)embolism)

4.4. Follow ABCFollow ABC

5.5. Bacterial isolates: C/S impt.Bacterial isolates: C/S impt.a.a. Gram (-) rods (vibrio sp.)Gram (-) rods (vibrio sp.)

b.b. Staph / strepStaph / strep

6.6. Tetanus vaccineTetanus vaccine

Marine Trauma & Marine Trauma & EnvenomationEnvenomation

Considerations:Considerations:– Antibiotics:Antibiotics:

1.1. 33rdrd generation cephalosphorin generation cephalosphorin2.2. QuinolonesQuinolones3.3. GentamicinGentamicin4.4. Trimethoprin-sulfamethoxazoleTrimethoprin-sulfamethoxazole

– Debridement Debridement = to lower infection & promote = to lower infection & promote healinghealing

– Wound are loosely closed & drained; primary Wound are loosely closed & drained; primary closure of distal extremity are avoided.closure of distal extremity are avoided.

– AntiveninAntivenin if available is given after skin if available is given after skin testingtesting

Injuries from Nonvenous Injuries from Nonvenous Aquatic Animals:Aquatic Animals:

1.1. SHARK:SHARK:– tiger / great white / bull sharktiger / great white / bull shark– Most injuries are lower extremitiesMost injuries are lower extremities– Powerful jaws & sharp teeth produces Powerful jaws & sharp teeth produces

crushing & tearing injuriescrushing & tearing injuries– Causes of death:Causes of death:

1.1. hypovolemic shockhypovolemic shock

2.2. drowningdrowning

Injuries from Nonvenous Injuries from Nonvenous Aquatic Animals:Aquatic Animals:

2.2. Moray Eels:Moray Eels:– Residing in holes or crevices at the Residing in holes or crevices at the

floor of the seafloor of the sea– Bites and produces multiple puncture Bites and produces multiple puncture

woundswounds– Hands is the most frequently bittenHands is the most frequently bitten

3.3. Alligators / CrocodileAlligators / Crocodile– Similar to shark bitesSimilar to shark bites

Injuries from Injuries from VenomousVenomous Aquatic Invertebrates Animals:Aquatic Invertebrates Animals:

1.1. Coelenterates:Coelenterates: (Jelly fish)(Jelly fish)– Venomous stinging cells called Venomous stinging cells called

nematocytenematocyte

Mild envenomation:Mild envenomation: Sting produces skin irritationSting produces skin irritation

1.1. Pruritus, paresthesia & throbbing painPruritus, paresthesia & throbbing pain

2.2. Edema and erythema ----> blisters & Edema and erythema ----> blisters & petechia ----> local infection & petechia ----> local infection & ulceration.ulceration.

Injuries from Venous Aquatic Injuries from Venous Aquatic Invertebrates Animals:Invertebrates Animals:

1.1. Coelenterates:Coelenterates: (Jelly fish)(Jelly fish)

Systemic envenomation:Systemic envenomation:– Manifestation of anaphylactic rxnManifestation of anaphylactic rxn

– Fever, N/V, body malaiseFever, N/V, body malaise

– Death due to hypotension and cardio-Death due to hypotension and cardio-respiratory arrest.respiratory arrest.


1.1. Coelenterates:Coelenterates: (Jelly fish) (Jelly fish)Treatment:Treatment:– Clean the wound w/ sea waterClean the wound w/ sea water– Apply diluted 5% Apply diluted 5% acetic acid (vinegar) or acetic acid (vinegar) or

baking soda; baking soda; it can inactivate the toxin; it can inactivate the toxin; applied for 30 mins or until the pain is applied for 30 mins or until the pain is relievedrelieved

– After wound irrigation ---> remaining After wound irrigation ---> remaining nematocyst are removed by applying shaving nematocyst are removed by applying shaving cream and shave the area w/ razorcream and shave the area w/ razor

– Local anesthesia, atihistamine or steroids can Local anesthesia, atihistamine or steroids can relieve pain after the toxin is inactivated.relieve pain after the toxin is inactivated.

– Prophylactic antibiotic are usually Prophylactic antibiotic are usually unnecessaryunnecessary


2.2. Echinodermata Echinodermata ((sea urchins & sea sea urchins & sea cucumber)cucumber)

– Causes contact dermatitisCauses contact dermatitis– Sea cucumbers feeds on coelenterates Sea cucumbers feeds on coelenterates

and secrete nematocytes hence local and secrete nematocytes hence local therapy for coelenterates shd be donetherapy for coelenterates shd be done

– Sea urchins – venomous spines Sea urchins – venomous spines causing local & systemic rxn like causing local & systemic rxn like coelenteratescoelenterates


2.2. Echinodermata Echinodermata ((starfish, seastarfish, sea urchins & sea cucumberurchins & sea cucumber))

Treatment:Treatment:– Soak w/ hot waterSoak w/ hot water– Spines of the organism located w/ x-Spines of the organism located w/ x-

ray or MRI and shd be removedray or MRI and shd be removed– Swelling alleviated w/ steroidsSwelling alleviated w/ steroids


3.3. Mollusks Mollusks ((octopusoctopus):):– Can bite & inject tetrodoxine Can bite & inject tetrodoxine

(paralytic agent)(paralytic agent)– Tx: Tx:

pressure & immobilize to contain pressure & immobilize to contain venomvenom

Systemic complication --- supportiveSystemic complication --- supportive

Injuries from Venous Aquatic Injuries from Venous Aquatic Vertebrates Animals:Vertebrates Animals:

1.1. Stingrays:Stingrays:– Whiplike appendages w/ spinesWhiplike appendages w/ spines at at

its end that can produce puncture its end that can produce puncture wounds & lacerationswounds & lacerations

– VenomVenom = vasoconstrictions causing = vasoconstrictions causing cyanosis of wound ----> cyanosis of wound ----> myonecrosismyonecrosis

– Systemic rxn:Systemic rxn:1.1. Cardiac arrhythmiaCardiac arrhythmia

2.2. Respiratory arrestRespiratory arrest

3.3. seizuresseizures


1.1. Stingrays:Stingrays:Treatment:Treatment:– Wound irrigated and soaked w/water Wound irrigated and soaked w/water

for an hourfor an hour– Debridement, exploration and removal Debridement, exploration and removal

of spinesof spines– Wound is elevated, dressed and not Wound is elevated, dressed and not

closed primarilyclosed primarily– Pain relieved locally and systemicallyPain relieved locally and systemically


2.2. Sea Snakes:Sea Snakes: ( (HydrophiidaeHydrophiidae))– neurologic sign and symptomsneurologic sign and symptoms– Death is due to paralysis and resp. Death is due to paralysis and resp.

arrestarrest– Tx similar to coral snakeTx similar to coral snake

Pressure, immobilize techniquePressure, immobilize technique Antivenin administration 1 ampule initially Antivenin administration 1 ampule initially

then repeated as neededthen repeated as needed

THANK YOUTHANK YOU

Health & Medicine

Animal And Insect Bites